ENHANCED TETANUS SURVEILLANCE
Responsible Centre:
Immunisation, Hepatitis, and Blood Safety Department
Centre for Infectious Disease Surveillance and Control
Public Health England
61 Colindale Avenue, London, NW9 5EQ
Telephone: 020 8327 7621
Fax: 020 8327 7404
CIDSC use only:
Number
Week of notification
Source of reporting
PERSONAL DETAILS
Name:
Sex: ☐Male ☐Female Age:
yrs or DoB: __/__/__
Ethnic group:
☐White
☐Mixed / Multiple
☐White British
☐White / Black Caribbean
☐Irish
☐White / Black African
☐Gypsy/Traveller
☐White / Asian
Any other ethnic background, please describe:
Place of Residence:
☐Asian / Asian British
☐Indian
☐Pakistani
☐Bangladeshi
Recent travel abroad? ☐yes ☐no ☐not known
☐Black / Black British
☐African
☐Caribbean
☐Other
☐ Arab
☐Chinese
If yes, dates of travel: __/__/__ to __/__/__
If yes, place travelled to:
Recent travel within the UK? ☐yes ☐no ☐not known
If yes, dates of travel: __/__/__ to __/__/__
If yes, place travelled to:
Occupation:
CLINICAL DETAILS
Date of onset of tetanus: __/__/__
Duration of illness:
days
Date of admission to hospital: __/__/__
Presenting features:
☐Trismus ☐Spasticity ☐Dysphagia ☐Respiratory embarrassment
☐Spasms ☐Autonomic dysfunction
☐Other, please specify:
Was this patient treated with tetanus immunoglobulin (TIG) or Vigam? ☐TIG ☐Vigam
☐no ☐not known
If yes, dates of onset of treatment: __/__/__
If yes, route of injection of TIG / Vigam: ☐ IM ☐IV ☐not known
Final grade of severity of illness:
mild to moderate trismus and general spasticity, little or no dysphagia, no respiratory
☐ Grade 1 (mild):
embarrassment
moderate trismus and general spasticity, some dysphagia and respiratory
☐ Grade 2 (moderate):
embarrassment, and fleeting spasms occur.
severe trismus and general spasticity, severe dysphagia and respiratory difficulties,
☐ Grade 3a (severe):
and severe and prolonged spasms (both spontaneous and on stimulation).
☐ Grade 3b (very severe): as for severe tetanus plus autonomic dysfunction, particularly sympathetic overdrive.
During the clinical course did the patient require admission to an intensive care or high dependency unit?
☐yes ☐no ☐not known
Last updated 14 July 2014
Please return the questionnaire by fax 020 8327 7404 FOA Sarah Collins (tel: 0208 327 7621)
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OUTCOME
☐Discharged
☐Still inpatient ☐Died Post mortem done? ☐yes ☐no ☐not known
Dates:__/__/__
__/__/__
__/__/__
if died, cause of death
If the final outcome for this case if is not yet available please complete the other sections of this form and
return to the address below.
HISTORY AND TREATMENT OF INJURY
Was there a known or suspected underlying injury? ☐yes ☐no ☐not known If yes, date of injury: __/__/__
Did the injury take place at:
☐Work
☐Home/garden
☐Street/Road Accident
☐Other (specify):
Please describe the circumstances of the injury:
Was treatment given at the time of injury (before onset of tetanus)? ☐yes ☐no ☐not known
If yes, which of the following were given:
Antibiotics
☐yes ☐no ☐not known
Debridement
☐yes ☐no ☐not known
Tetanus toxoid
☐yes ☐no ☐not known
Tetanus immunoglobulin ☐yes ☐no ☐not known
☐Other (please specify)
IMMUNISATION HISTORY
Was there a history of any previous tetanus immunisation? ☐yes ☐no ☐not known
If yes, please list tetanus immunisation courses below
Given?
Date
Dose 1 ☐yes ☐no ☐not known __/__/__
Dose 2 ☐yes ☐no ☐not known __/__/__
Dose 3 ☐yes ☐no ☐not known __/__/__
Dose 4 ☐yes ☐no ☐not known __/__/__
Dose 5 ☐yes ☐no ☐not known __/__/__
Any tetanus boosters given following 5th dose: ☐yes ☐no ☐not known
If yes, please list dates: __/__/__, __/__/__, __/__/__, __/__/__
MICROBIOLOGY
Have tetanus antitoxin levels been measured? ☐yes ☐no ☐not known If yes, date : __/__/__ level
iu/ml
Has tetanus been cultured? ☐yes ☐no ☐not known
Was tetanus toxin found in serum? ☐yes ☐no ☐not known If yes, date : __/__/__
INJECTING DRUG USE
Did the case inject drugs in the past 6 months? ☐yes ☐no ☐not known
Duration of injecting drug use?
years
If NO then please go to the end.
months
Did the case inject drugs in the past month? ☐yes ☐no ☐not known
If NO then please go to the end.
Last updated 14 July 2014
Please return the questionnaire by fax 020 8327 7404 FOA Sarah Collins (tel: 0208 327 7621)
Page 2 of 4
INJECTING DRUG USE
Which of the following routes where used to take drugs in the past month? (please tick all that apply)
Which was the main route of use? (please tick one)
Smoking
☐yes ☐no ☐not known
☐main
Snorting or sniffing
☐yes ☐no ☐not known
☐main
Subcutaneous injection (Skin popping)
☐yes ☐no ☐not known
☐main
Intramuscular injection (Muscle popping)
☐yes ☐no ☐not known
☐main
Injecting into a vein (Mainlining)
☐yes ☐no ☐not known
☐main
Other, please specify :
If they had injected in to veins, did they at any time in the past month miss a vein? ☐yes ☐no ☐not known
Which of the following drugs or drug combinations did they inject in the past month? (tick all that apply)
Which was the main drug or drug combination they used? (tick one)
Heroin alone
☐yes ☐no ☐not known
☐main
Crack alone
☐yes ☐no ☐not known
☐main
Cocaine alone
☐yes ☐no ☐not known
☐main
Heroin & crack together
☐yes ☐no ☐not known
☐main
Heroin & cocaine together
☐yes ☐no ☐not known
☐main
Methadone
☐yes ☐no ☐not known
☐main
Other opiate
☐yes ☐no ☐not known
☐main
Amphetamines
☐yes ☐no ☐not known
☐main
Benzodiazepines
☐yes ☐no ☐not known
☐main
Other, please specify
If yes, which drug or drugs
Had the appearance of any of the drugs they used changed in the past month? ☐yes ☐no ☐not known
If yes, which drug or drugs
Did the dealer, or supply, of the drugs they use change within the past month? ☐yes ☐no ☐not known
Please list all the areas (town or city) from which drugs were bought in the past month:
Please list the site(s) of injecting in the last month:
Arm
☐yes ☐no ☐not known
Hand ☐yes ☐no ☐not known
Leg
☐yes ☐no ☐not known
Neck ☐yes ☐no ☐not known
Groin ☐yes ☐no ☐not known
Other, please specify:
What did they use to dissolve drugs in the last month?
☐Citric acid ☐Ascorbic acid (vit. C) ☐Lemon juice ☐Vinegar ☐Other (specify)
In the last month had any of the drugs they had used require more citric acid/ascorbic acid/vinegar/lemon
juice than usual to dissolve? ☐yes ☐no ☐not known
Last updated 14 July 2014
Please return the questionnaire by fax 020 8327 7404 FOA Sarah Collins (tel: 0208 327 7621)
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For the next set of questions a ‘public place’ is street, road, alleyway, park, woodland, waste ground, towpath,
under a bridge, or public toilet.
In the last month did they?
Buy/get drugs off a dealer, or friend, in a ‘public place’ or abandoned building?
☐yes ☐no ☐nk
Use needle/syringe (works) that had been discarded by someone else?
☐yes ☐no ☐nk
Use needle/syringe (works) that they found in a ‘public place’ or abandoned building?
☐yes ☐no ☐nk
Use a filter that had been discarded by someone else?
☐yes ☐no ☐nk
Use a filter that they found in a ‘public place’ or abandoned building?
☐yes ☐no ☐nk
Use a spoon or other mixing container that had been discarded by someone else?
☐yes ☐no ☐nk
Use a spoon or other mixing container, that they found in a ‘public place’ or abandoned building? ☐yes ☐no ☐nk
Use a filter from a cigarette they had picked up off the floor or ground?
☐yes ☐no ☐nk
Sleep rough in a ‘public place’ or abandoned building?
☐yes ☐no ☐nk
In the last month did they inject in any of these locations?
An abandoned building
☐yes ☐no ☐nk
A street, road, or alleyway
☐yes ☐no ☐nk
A park
☐yes ☐no ☐nk
Woodland or waste ground
☐yes ☐no ☐nk
Towpath or under a bridge
☐yes ☐no ☐nk
A public toilet
☐yes ☐no ☐nk
Hostel
☐yes ☐no ☐nk
Squat
☐yes ☐no ☐nk
Do they usually clean their injection site with iodine, alcohol, or steret/mediswab before injecting? ☐yes ☐no ☐nk
Do they usually wash their injection site with soap and water before injecting?
☐yes ☐no ☐nk
Do they usually wash their hands before injecting?
☐yes ☐no ☐nk
What local signs were associated with injection site/s?
Large abscess
☐yes ☐no ☐nk
Extensive cellulitis
☐yes ☐no ☐nk
Extensive oedema
☐yes ☐no ☐nk
Extensive necrosis
☐yes ☐no ☐nk
Extensive induration
☐yes ☐no ☐nk
Form Completed by:
Date: __/__/__
Telephone:
Please give any additional comments below:
Last updated 14 July 2014
Please return the questionnaire by fax 020 8327 7404 FOA Sarah Collins (tel: 0208 327 7621)
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